Discharge Planning

2008 Conference

Planning Committee

The conference held on September 24, 2008 was a success. Over 340 participants from across the continuum of care attended. The evaluations indicated that 94% of the attendees rated the program from good to excellent.

Consumer Information Guide to Discharge Planning

What Consumers and Their Families Need to Know Before Being Discharged to Home Care

You have the right and responsibility to be involved in your plan of care. To the greatest extent possible, consumers should be an active participant in developing that plan. Below are questions to help you and your family with your discharge and future health needs.

Do you have your insurance cards or other documents?

Do you and your family feel that your current medical and mental health status is stable enough to be discharged to home care?

Do you have family or other people at home to assist you at home?

If not, are you comfortable taking care of yourself as needed?

Do you need people to take care of you?

Do you know how you and your family will be paying for your care? Do you think you are eligible for Medicare and/or Medicaid? Do you have private insurance or will you and/or your family be paying for your care?

Are you and/or your family comfortable that you and/or they can make important decisions about your health care needs? Do you and/or you family feel it is necessary to consult a professional about your decision making status?

Do you feel comfortable that you and/or your family understand your physician's expectations about your health status and decision to be cared for at home?

What are your expectations/goals for your immediate and short term health care needs?

What are your expectations for your long term care?

What are the expectations/goals of your family and/or other informal supports assisting you in your care?

What services did you have prior to admission?

Do you know the name of the agency or facility that provided those services?

Do you expect that those services will be provided at the same level of service? Will that be sufficient or is an increase in hours needed? Is your provider willing to reinstate services? If not, why?

Do you know how to access services?

Does your primary care physician or person on your medical team need to be contacted? Do you know which physician will be responsible for overseeing your care at home?

Do you and/or your family feel that your home is adequately equipped for you to be cared for at home?

What Consumers Need to Know About Their Abilities and Responsibilities:

For consumers with newly acquired disabilities, the consumer needs to understand his/her condition from both a medical perspective and what it will mean to live with a disability. Physicians should discuss with the consumer physical changes, probable care needs, possible complications and other things to watch for related to the disability. Peer support should be offered to each consumer. Peer support is available through the local Independent Living Center, as well as various disability specific support groups.

Consumers should know their right to receive services in the most integrated setting and who to contact if they feel that right is not being fulfilled.

The consumer needs to have a firm understanding of what assistance he/she will need or want and how to best benefit from the available assistance.

The consumer needs to understand what services and supports are available to meet his/her needs and desires. The discharge planner needs to know what services are available to meet the needs and desires of the consumer and the eligibility requirements of available services and supports.

As long-term planning, consumers should be given information on what services or supports are available, and contact information for assistance and advocacy, should their needs change.

The consumer and discharge planner must have a clear understanding of the role of any informal supports. The consumer and discharge planner should candidly explain this role to the informal supports in order to ensure that they understand their role. If informal supports have agreed to be part of the Discharge Plan, the consumer and discharge planner must ensure that the informal supports understand what will happen if they do not fulfill their role.

Consumers need to understand what types of services and supports their medical insurance will cover and for what public benefits they may be eligible. Discharge planners should be familiar with basic guidelines for Medicare and Medicaid coverage, and refer consumers to the appropriate person or entity that can explain specific coverage benefits and limitations.

Consumers should have a firm understanding of their rights to appeal adverse decisions.